Form 3 Form 3 Nursing Home Site Information Form

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Attachment C: Nursing Home Site Information Form

Response options for bed size:

• 1-49

• 50-99

• 100-199

• 200 or more

Response options for Who Administered to:

• All staff/Sample of staff

• Selected departments/units only (please specify)

• Selected staff positions only (please specify)

• Selected departments/units and selected staff positions (please specify)

Response options for control/operation:

• For profit – operated under private commercial ownership

• Non profit – operated under voluntary or other nonprofit auspices

• Government – operated by a government entity

Response options for Survey Mode:

• Paper

• Web

• Mixed mode (paper & web)

• Other

Response options administration of WPS:

• Yes

• No

Public reporting burden for this collection of information is estimated to average 5 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, # 7, Rockville, MD 20857.